Cerebral oxygenation in the beach chair position: a prospective study on the effect of general anesthesia compared with regional anesthesia and sedation.
J Shoulder Elbow Surg. 2013 Apr 6
In 60 patients scheduled for shoulder surgery with interscalene block sedation (n=30) or sevoflurane general anesthesia (n=30) in beach chair (BC) position without a controlled hypotension protocol, the authors analyzed the incidence of cerebral desaturation events (CDEs).
Regional cerebral saturation levels in the awake group did not differ from baseline and were significant higher compared with the asleep group 30 minutes after induction for most of the surgery time. However, mean arterial pressure measured non-invasively at heart level was only different between the groups 12 minutes after induction (time of BC positioning), otherwise there was only a difference compared with baseline in the asleep group, and inconstantly after 30 minutes in the regional anesthesia group as well. The incidence of CDEs in the asleep group was 56.7% compared with 0% in the regional anesthesia group. Absolute regional cerebral saturation levels <55% were seen in 23.3% in the asleep group vs. 3.3% in the regional anesthesia group. A total of 89% of combined DSEs were documented in the asleep group compared with one in the regional anesthesia group. The aldrete recovery room scores were significantly improved in the awake group for the first 45 minutes of postanesthesia care unit (PACU) admission and this group met discharge criteria a mean of 22.5 minutes earlier.
These findings confirm, on the one hand, that BC for shoulder surgery bears some risks despite the low incidence of catastrophic events (tetraplegia, brain damage and death). On the other hand, there are important limitations in this study. First, a commonly used controlled hypotension protocol was not used, masking possible effects of low blood pressure. Second, there was a treatment protocol for CDEs meaning that the events were corrected as they appeared influencing the number of possible additional CDEs and the possible effects on clinical outcome. Additionally, this protocol included phenylephrine, which has been shown to impair cerebral autoregulation. Third, the authors only took one definition for CDE into account (regional cerebral saturation decrease >20% from baseline)...
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